Clinical Topic A-Z Clinical Speciality

Allergic rhinitis

Allergic rhinitis
D012221Rhinitis, Allergic, Perennial
D012220Rhinitis
AllergiesEar, nose and throatRespiratory
2012-11-01Last revised in November 2012

Allergic rhinitis - Summary

Allergic rhinitis is an inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitized to allergens.

People may be allergic to one or more allergens, which complicates their identification by history alone. The most common allergens include:

House dust mites.

Grass, tree, and weed pollens.

Allergens carried on animal hair.

Allergens encountered at work such as latex gloves and wood dust.

The symptoms of many people with seasonal allergic rhinitis improve over time. Some people develop asthma, eczema, or allergic conjunctivitis.

A person with rhinitis typically presents with sneezing, itching, and nasal discharge and/or blockage.

Allergy testing should be arranged when the type of rhinitis (infective, irritant, or allergic) is unclear from the history, or if symptoms are persistent or poorly controlled.

Referral for skin prick testing should be arranged, if available. Results can be suppressed by some drugs (e.g.antihistamines and topical corticosteroids).

If skin prick testing is not available or suitable, blood should be sent for serum total and specific immunoglobulin (Ig) E testing. If allergy testing is negative, non-allergic causes for the rhinitis (such as drugs and hormonal causes) should be considered.

Allergen avoidance is fundamental to the management of allergic rhinitis; however, drug treatment may be necessary. If nasal drops or a spray is prescribed, an explanation should be given of the importance of good technique.

For 'as-required' treatment for occasional symptoms, an antihistamine should be prescribed.

For people with allergic conjunctivitis, children aged 2 to 5 years of age, and people who prefer oral treatment, an oral antihistamine should be prescribed first-line.

For all other people, intranasal azelastine should be prescribed first-line.

For people who want preventive treatment to control more frequent or persistent symptoms, the importance of regular treatment should be explained.

If the predominant symptom is nasal blockage, or nasal polyps are present, an intranasal corticosteroid should be prescribed.

If the predominant symptoms are sneezing or nasal discharge, either an oral antihistamine or an intranasal corticosteroid should be prescribed.

For pregnant or breastfeeding women, an intranasal corticosteroid should be prescribed first-line.

For people who require rapid relief of symptoms while awaiting preventive treatment to take effect:

If nasal congestion is a problem, an intranasal decongestant should be prescribed.

If using an intranasal corticosteroid, an oral antihistamine should be prescribed.

If symptoms are severe and impairing quality of life, a course of oral prednisolone should be prescribed.

People should be advised to reconsult after 2–4 weeks if symptoms remain inadequately controlled.

Treatment should be continued until they are no longer likely to be exposed to the suspected allergen.

People with recurrent episodes of allergic rhinitis controlled by intranasal corticosteroids should be advised to restart treatment at least 7 days before re-exposure to allergen. When the time of re–exposure to the antigen is uncertain, treatment should be started several weeks before the most likely time of re–exposure.

If there is inadequate benefit with current treatment, step-up treatment should be considered.

Have I got the right topic?

24months3060monthsBoth

This CKS topic covers the management of allergic rhinitis including perennial, occupational, and seasonal rhinitis (hay fever).

There are separate CKS topics on Asthma, Eczema - atopic, Conjunctivitis - allergic, and Sinusitis.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in November 2012

November 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to clinical recommendations have been made.

Previous changes

September 2012 — minor update. Ephedrine 0.5% nasal drops are no longer licensed for use in children younger than 12 years of age. Text and prescriptions have been updated.

June 2012 — minor update. Typographical error corrected.

January 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

August 2009 — minor update. Xylometazoline 0.05% nasal drops (Otrivine Child Nasal Drops®) are no longer licensed for use in children between 2 and 5 years of age. They can be prescribed for children who are 6 years of age and over. Issued in August 2009.

May 2009 — minor formatting correction. Issued in June 2009.

October 2007 to January 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

The previous system of classifying a person with allergic rhinitis by the persistence and severity of their symptoms to determine management has been modified. Management is now divided into whether or not a person with symptoms of allergic rhinitis is presently on treatment, and this is reflected in the scenarios offered.

July 2006 — minor update. Levocabastine products discontinued and prescriptions removed. Issued in July 2006.

April 2006 — minor update. Montelukast now licensed for symptomatic relief of seasonal allergic rhinitis in people with asthma in whom montelukast is indicated. Text and prescriptions updated to reflect this. Issued in May 2006.

January 2006 — minor update. Black triangle removed from desloratadine. Issued in February 2006.

October 2005 — minor technical update. Issued in November 2005.

July 2005 — updated to include sodium cromoglicate eye drops for use in pregnancy. Issued in July 2005.

December 2004 — rewritten. Validated in March 2005 and issued in April 2005.

December 2001 — rewritten, replacing previous guidance called Allergic rhinitis/hay fever. Validated in March 2002 and issued in April 2002.

September 1998 — written.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 September 2012.

HTAs (Health Technology Assessments)

No new HTAs since 1 September 2012.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2012.

Systematic reviews and meta-analyses

Systematic reviews published since the last revision of this topic:

Brinkhaus, B., Ortiz, M., Witt, C.M., et al. (2013) Acupuncture in patients with seasonal allergic rhinitis: a randomized trial. Annals of Internal Medicine 158(4), 225-234. [Abstract]

Enrico, C. and Walter Canonica, G. (2013) Efficacy and safety of rupatadine for allergic rhino-conjunctivitis: a systematic review of randomized, double-blind, placebo-controlled studies with meta-analysis. Current Medical Research and Opinion 29(11), 1539-1551. [Abstract]

Hermelingmeier, K.E., Weber, R.K., Helllmich, M., et al. (2012) Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis. American Journal of Rhinology and Allergy 26(5), 119-125. [Abstract]

Lin, S.Y., Melvin, T.A., Boss, E.F., and Ishman, S.L. (2013) The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review. International Forum of Allergy and Rhinology 3(6), 504-509. [Abstract]

Lohia, S., Schlosser, R.J., and Soler, Z.M. (2013) Impact of intranasal corticosteroids on asthma outcomes in allergic rhinitis: a meta-analysis. Allergy 68(5), 569-579. [Abstract]

Primary evidence

Randomized controlled trials published since the last revision of this topic:

Brinkhaus, B., Ortix, M., Witt, C.M., et al. (2013) Acupuncture in patients with seasonal allergic rhinitis: a randomized trial. Annals of Internal Medicine 158(4), 225-234. [Abstract]

New policies

No new national policies or guidelines since 1 September 2012.

New safety alerts

No new safety alerts since 1 September 2012.

Changes in product availability

No changes in product availability since 1 September 2012.

Goals and outcome measures

Goals

To control symptoms with the most acceptable treatment

To refer people with refractory symptoms as appropriate

Background information

Definition

What is it?

Allergic rhinitis is an inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitized to allergens:

Sensitization to an allergen results in the production of immunoglobulin (Ig) E which is specific to that allergen. This IgE binds to the surface of mast cells in the lining of the nose.

Re-exposure to the allergen results in the allergen binding to IgE on the surface of mast cells. This triggers the release of histamine and other inflammatory mediators.

Histamine and other inflammatory mediators act on cells, nerve endings, and blood vessels to produce sneezing, itching, nasal discharge (rhinorrhoea), and nasal obstruction.

Allergic rhinitis is associated with the development of allergic conjunctivitis, eczema, and asthma.

[ARIA, 2010]

Classifying allergic rhinitis

How is allergic rhinitis classified?

Allergic rhinitis has historically been classified as seasonal, perennial, or occupational:

Seasonal — when symptoms occur at the same time each year. If caused by grass and tree pollen allergens, it is also known as 'hay fever'.

Perennial — when symptoms occur throughout the year, typically because of allergens from house dust mites and pets.

Occupational — when symptoms are due to exposure to allergens at work, for example flour allergy in a baker.

Allergic rhinitis more recently has been classified by severity and persistence of symptoms as:

Mild intermittent.

Moderate severe intermittent.

Mild persistent.

Moderate severe persistent.

[ARIA, 2010]

These classifications are used in the literature regarding the timing of symptoms or their severity or persistence. However, they are less useful in clinical practice.

Common allergens causing rhinitis

What are the common allergens causing rhinitis?

People may be allergic to one or more allergens, which complicates their identification by history alone. The most common allergens include:

House dust mites:

These feed on shed human skin flakes which are particularly abundant in mattresses, bed bases, pillows, carpets, upholstered furniture, and furry toys.

Their growth is maximal at temperatures above 20°C and when humidity is above 80%. When humidity falls below 50%, they die.

They are present all year-round, but their numbers tend to peak in the spring and autumn.

Grass, tree, and weed pollens. The length, duration, and intensity of the pollinating season varies from year to year, which can complicate identification of the responsible allergen.

Trees generally pollinate in the spring.

Grasses pollinate at the end of spring and beginning of summer.

Weeds may pollinate from early spring to late autumn.

Allergens carried on animal hair:

Cats and dogs are the most common animals associated with causing allergic rhinitis.

Less commonly, dander from horses, cattle, rabbits, and rodents (such as guinea pigs, hamsters, and rats) may cause allergic rhinitis.

Allergens encountered at work [Moscato and Siracusa, 2009]:

The incidence of allergic rhinitis is increased in certain occupations, such as working with latex gloves, flour, and wood dust.

[Ryan et al, 2008; ARIA, 2010]

Prevalence

How common is it?

Allergic rhinitis affects 30% of the world's population, and 20% of the UK population [Scadding et al, 2008], and is increasing in incidence [Ryan et al, 2008; ARIA, 2010; Jacobs, 2011].

The incidence of the type and severity of allergic rhinitis is related to age [ARIA, 2010]:

Children of school age and adolescents are most commonly affected by seasonal allergic rhinitis.

Adults are more likely to have perennial allergic rhinitis.

Complications and prognosis

Complications

Allergic rhinitis is underestimated as a cause of impaired quality of life:

Although it is not usually a severe disease, symptoms of allergic rhinitis can adversely affect work, home, and social life [Scadding et al, 2000; ARIA, 2010; Greiner et al, 2012].

In children, poorly controlled symptoms may contribute to learning problems and sleep disturbance [van Cauwenburge et al, 2000; Ryan et al, 2008; ARIA, 2010].

Allergic rhinitis and asthma often co-exist and symptomatic rhinitis is a major risk factor for poor asthma control and exacerbation of symptoms [Angier et al, 2010; Greiner et al, 2012].

Evidence from epidemiological studies suggest that asthma is found in 15–38% of people with allergic rhinitis. Some studies estimate that nasal symptoms are present in at least 75% of people with asthma, but these estimates vary widely from 6% to 85% depending on the study [Ryan et al, 2008; ARIA, 2010].

Sinusitis is a common complication of allergic rhinitis. It is thought that swelling of the nasal mucosa leads to obstruction of the drainage of the sinuses, predisposing to the development of sinusitis [ARIA, 2008].

Prognosis

In many people with seasonal allergic rhinitis, symptoms improve over time. Studies have reported spontaneous 'cure' rates of 10–20% and improvement rates of 40–65% over 5–23 years of follow up [Greisner et al, 1998].

Many people develop asthma following the development of allergic rhinitis. It is believed that effective avoidance of the allergens known to cause allergic rhinitis may prevent the development of asthma [ARIA, 2008].

Diagnosis

Diagnosis of allergic rhinitis

Diagnosis

How should I diagnose allergic rhinitis?

A person with allergic rhinitis typically presents with sneezing, itching, nasal discharge (rhinorrhoea), and blockage. Eye symptoms such as bilateral itching, redness, and swelling are also usually associated with allergic rhinitis.

Most cases of allergic rhinitis are diagnosed by identifying its characteristic features and excluding infectious and irritant causes of rhinitis.

An infective cause for rhinitis is more likely when:

There is an acute onset of 1 week or less.

There are typical features of an associated upper respiratory tract infection, such as cough, fever, or lymphadenopathy.

Nasal discharge is green or yellow (yellow nasal discharge may also be indicative of allergic rhinitis). If discharge is clear, infection is unlikely.

An irritant cause for rhinitis is more likely when symptoms follow a known physical or chemical exposure:

Physical irritant rhinitis may follow changes in temperature or humidity, or occur with exercise.

Chemical irritant rhinitis may follow exposure to volatile chemicals and odours.

Allergic rhinitis and irritant rhinitis may coexist. When they do, irritant rhinitis tends to be more severe.

If infective and irritant causes have been excluded, ask about the characteristic features of allergic rhinitis, including:

Personal or family history of atopy (asthma, eczema, or allergic rhinitis).

Occurrence of symptoms following exposure to a known allergic cause of rhinitis, such as:

House dust mites — symptoms are worse on waking and are present all-year-round, but may peak in autumn and spring.

Animal dander — symptoms follow exposure to animal dander. Symptoms may be all-year-round or occasional, depending on exposure.

Tree pollens — intermittent or chronic symptoms occur from early to late spring.

Grass pollens — intermittent or chronic symptoms occur from late spring to early summer.

Weed pollens — intermittent or chronic symptoms may occur from early spring to early autumn.

Allergens encountered at work — intermittent or chronic symptoms tend to improve when the person is away from work at weekends and on holidays.

Rhinitis associated with nasal itching.

Symptoms that are controlled by antihistamines or topical corticosteroids.

Arrange allergy testing when the type of rhinitis (infective, irritant, or allergic) is unclear from the history, or if symptoms are persistent or poorly controlled. Be aware that the results of skin prick tests can be suppressed by antihistamines, tricyclic antidepressants (TCAs), and topical corticosteroids.

Refer to an immunologist for skin prick testing, if available.

If skin prick testing is not available or the person is taking an antihistamine, a TCA, or is using a topical corticosteroid, send blood for serum total and specific immunoglobulin (Ig) E testing (radioallergosorbent test [RAST] or enzyme-linked immunosorbent assay [ELISA]).

If allergy testing is negative, consider non-allergic causes for the rhinitis, including drugs, hormonal causes, and non-allergic rhinitis with eosinophilia syndrome. For further information, see Differential diagnosis.

Basis for recommendation

Basis for recommendation

Diagnosis of allergic rhinitis:

Recommendations for diagnosing allergic rhinitis are based on expert opinion from review articles [Quillen and Feller, 2006; Saleh and Durham, 2007; Ryan et al, 2008] and on a primary care guideline for the management of allergic and non-allergic rhinitis [Angier et al, 2010].

Skin prick tests:

Evidence from one controlled trial showed that skin prick testing is superior to patient-reported allergies or obtaining a structured allergy history [Smith et al, 2009] although it is not perfect [Rusznak and Davies, 1998; Khan, 2009].

Results of skin prick tests can be suppressed by drugs, such as antihistamines, topical corticosteroids, and tricyclic antidepressants.

Skin prick tests are less reliable with food allergens than with inhaled allergens.

Interpretation of test results may be difficult in people with eczema.

Differential diagnosis

What else might it be?

Infective rhinitis.

Irritant rhinitis.

Non-allergic causes of rhinitis, including:

Autonomic (vasomotor) rhinitis. This is thought to be caused by parasympathetic hyperactivity. It may be difficult to distinguish from allergic rhinitis as symptoms are similar; however, a person with autonomic rhinitis tends to have less itch and more rhinorrhoea (especially in the morning). Autonomic rhinitis may be exacerbated by changes in air temperature, tobacco smoke, and perfumes.

Drugs. Drug-induced rhinitis should be considered when symptoms follow the start of treatment with certain drugs, such as angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, chlorpromazine, aspirin, nonsteroidal anti-inflammatory drugs, and cocaine. Rebound symptoms may occur when stopping treatment with nasal decongestants.

Hormones. Hormonal rhinitis should be considered when symptoms coincide with pregnancy, starting the oral contraceptive pill, or hypothyroidism.

Food and drink. Alcohol and spicy foods may cause rhinorrhoea and facial flushing.

Rarely, non-allergic rhinitis with eosinophilia syndrome (NARES). This is characterized by nasal eosinophils in people with perennial symptoms, and occasionally reduced sense of smell. It is diagnosed only when other causes of rhinitis, including allergic rhinitis, have been excluded.

Conditions that can mimic the symptoms of rhinitis, including:

Structural or mechanical factors, such as deviated nasal septum, nasal polyps, hypertrophic turbinates, adenoidal hypertrophy, foreign bodies, and (rarely) nasal tumours.

Systemic conditions, such as primary defects in mucus production (for example cystic fibrosis), primary ciliary dyskinesia (Kartagener's syndrome), and granulomatous disease (for example Wegener's granulomatosis and sarcoidosis).

Basis for recommendation

Basis for recommendation

Information on the differential diagnosis of allergic rhinitis is based on expert opinion from review articles [Quillen and Feller, 2006; Wallace and Dykeqicz, 2008].

Management

Management

Scenario: Starting treatment : covers the management of people with all types of allergic rhinitis who are not presently on any drug treatment.

Scenario: Stepping-up treatment : covers the management of people with all types of allergic rhinitis who are presently on drug treatment but with poorly controlled symptoms.

Scenario: Starting treatment

Scenario: Starting treatment for allergic rhinitis

24months3060monthsBoth

Assessment

How should I assess allergic rhinitis?

Assess for symptoms of asthma and manage accordingly. For further information see the CKS topic on Asthma.

Try to identify the most likely allergen causing symptoms:

The responsible allergen may be identifiable from the history — see Diagnosis.

Allergy testing to confirm the responsible allergen is indicated when burdensome allergen avoidance strategies, such as house dust mite avoidance measures, are being considered.

Ask about factors that may influence the choice of drug treatment, including:

Frequency, severity, and persistence of symptoms.

The adverse effects of symptoms on quality of life, such as effect on sleep, recreation, and work.

Associated allergic conjunctivitis.

Previous treatments for allergic rhinitis and their effectiveness.

Personal preference for oral or intranasal treatments.

Look for signs suggestive of chronic nasal congestion, such as breathing through the mouth, cough, and halitosis.

Examine the nose for:

Nasal polyps.

Deviated or perforated nasal septum.

Mucosal swelling.

Depressed nasal bridge or widened bridge.

Horizontal nasal crease across nose dorsum (in severe rhinitis).

Basis for recommendation

Basis for recommendation

These are pragmatic recommendations based mainly on a primary care summary of the British Society for Allergy and Clinical Immunology guideline on the management of allergic and non-allergic rhinitis [Angier et al, 2010] and an American allergic rhinitis guideline [University of Michigan Health System, 2007].

Epidemiological studies have shown that allergic rhinitis is a risk factor for the development of asthma and usually precedes it. Optimal management of allergic rhinitis may improve coexisting asthma [Ryan et al, 2008; ARIA, 2010; Greiner et al, 2012].

House dust mite avoidance measures are not routinely recommended because they are inconvenient, expensive, and there is a lack of good quality evidence for their effectiveness. Skin prick testing, to confirm the responsible allergen, is indicated when such burdensome allergen avoidance strategies are being considered [Saleh and Durham, 2007].

Evidence from one controlled trial showed that skin prick testing is superior to patient-reported allergies or obtaining a structured allergy history [Smith et al, 2009] although it is not perfect [Rusznak and Davies, 1998; Khan, 2009].

Results of skin prick tests can be suppressed by drugs, such as antihistamines, topical corticosteroids, and tricyclic antidepressants.

Skin prick tests are less reliable with food allergens than with inhaled allergens.

Interpretation of test results may be difficult in people with eczema.

Management of allergic rhinitis

How should I manage a person with allergic rhinitis?

For people who want an 'as-required' treatment for occasional symptoms, prescribe an antihistamine first-line:

For people with allergic conjunctivitis, children aged 2–5 years of age, and people who prefer oral treatment, prescribe an oral antihistamine (such as cetirizine or loratadine).

For all other people, prescribe intranasal azelastine first-line. Explain the importance of a good technique.

For people who want preventive treatment to control more frequent or persistent symptoms:

Advise the person to avoid the causative allergen, if possible.

If allergen avoidance is inadequate or not possible, prescribe drug treatment. If nasal drops or a spray is prescribed, explain the importance of a good technique.

If the predominant symptom is nasal blockage, or nasal polyps are present, prescribe an intranasal corticosteroid (such as budesonide, fluticasone,or mometasone).

If the predominant symptom is sneezing or nasal discharge, prescribe an oral antihistamine (if oral treatment is preferred or allergic conjunctivitis is present) or an an intranasal corticosteroid (if a more effective treatment is required).

For pregnant or breastfeeding women, prescribe first-line intranasal corticosteroid.

If this is not tolerated or additional treatment is required, prescribe an oral antihistamine (loratadine).

Intranasal sodium cromoglicate and nasal douching (with normal saline) can be used as alternative or add on treatments.

For people who require rapid relief of symptoms while awaiting preventive treatment to take effect:

If nasal congestion is a problem, prescribe an intranasal corticosteroid for up to 7 days.

If using an intranasal corticosteroid, add an oral antihistamine.

If symptoms are severe and/or impairing quality of life, prescribe a 5–10 day course of prednisolone, 20–40 mg a day in adults and 10 mg a day in children.

Advise people to reconsult after 2–4 weeks if symptoms remain inadequately controlled.

For a discussion on the comparative advantages and disadvantages of different treatment regimens, see Advantages and disadvantages of first-line drug treatments.

Advantages and disadvantages of first-line drug treatments

Advantages and disadvantages of first-line drug treatments for allergic rhinitis

Table 1 shows some of the advantages and disadvantages of the different first-line drug treatments for allergic rhinitis.

Table 1 . Key characteristics of different first-line treatment options.
Relative efficacy — allergic rhinitis Relative efficacy — allergic conjunctivitis Onset of action Dose frequency
Intranasal antihistamine* ++ None Within 15 minutes Two to four times daily
Oral non-sedating antihistamine ++ ++ Within 1 hour Once-daily options available
Intranasal corticosteroids +++ ++ Within 12 hours Once-daily options available
* Not suitable for children < 5 years of age. † Maximum efficacy takes days or weeks to develop [ARIA, 2010].
Data from: [van Cauwenburge et al, 2000]

See Prescribing information for more information about the profiles of the recommended drugs.

Basis for recommendation

Basis for recommendation

Intranasal antihistamines for people preferring 'as-required' treatment for occasional symptoms:

This is a pragmatic recommendation based on evidence of the comparative speed of onset and efficacy of oral antihistamines compared with other treatments for allergic rhinitis. In addition:

Although intranasal corticosteroids are the most effective treatment for controlling symptoms of allergic rhinitis, their effect is not immediate and maximum relief may take days or weeks to be seen [University of Michigan Health System, 2007; Nathan, 2008; Wallace and Dykeqicz, 2008; Kaliner, 2009; Angier et al, 2010; ARIA, 2010; Greiner et al, 2012]. Intranasal antihistamines are preferred for controlling breakthrough symptoms in allergic rhinitis because of their rapid onset of action (within 15 minutes) [van Cauwenburge et al, 2000; Kaliner, 2009; BNF 64, 2012].

CKS recommends intranasal azelastine because it is the only intranasal antihistamine that is available and licensed in the UK for the treatment of allergic rhinitis [ABPI Medicines Compendium, 2009; BNF 64, 2012].

Oral antihistamines or an intranasal corticosteroids for people who want regular treatment to control more frequent or persistent symptoms:

This is a pragmatic recommendation based on evidence of the efficacy of intranasal corticosteroids and evidence of the efficacy of oral antihistamines to control symptoms. In addition:

The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines do not recommend the use of intranasal antihistamines in adults and children with perennial or persistent allergic rhinitis due to the lack of data on their relative long term efficacy and safety; they suggest that an oral non-sedating antihistamine should be used first-line instead [ARIA, 2010].

Experts agree that intranasal corticosteroids are the most effective treatment for controlling symptoms of allergic rhinitis when used on a regular basis [University of Michigan Health System, 2007; Nathan, 2008; Wallace and Dykeqicz, 2008; Kaliner, 2009; Greiner et al, 2012].

The British National Formulary advises that the short term use of an intranasal corticosteroid helps to shrink nasal polyps, although a short course of an oral steroid may be required initially to shrink large polyps [BNF 64, 2012].

Expert opinion in a published review article suggests that non-sedating oral antihistamines and nasal corticosteroids may be used regularly without fear of adverse consequences [Laekeman et al, 2010].

Pregnant and breastfeeding women:

Topical corticosteroids are recommended by experts in pregnancy and breastfeeding because their benefits are thought to outweigh their risks. Although there is a lack of safety data on pregnant women with allergic rhinitis, their use in pregnant women with asthma appears to be safe [Demoly et al, 2003; Wallace and Dykeqicz, 2008].

In pregnant women, topical antihistamines are preferred to oral antihistamines by experts because they have a faster onset of action, minimal systemic absorption, and do not expose the fetus to potential adverse effects [ABPI Medicines Compendium, 2009].

The oral antihistamines chlorphenamine, loratadine, and cetirizine are recommended by many experts for use in pregnancy [Schaefer et al, 2007; Angier et al, 2010]. Loratadine and cetirizine are recommended for use in breastfeeding women [Schaefer et al, 2007]. CKS recommends loratadine because there is more safety data available than for cetirizine, and it is not associated with the sedative adverse effects of chlorphenamine.

Intranasal sodium cromoglicate is recommended by experts as an alternative treatment when other treatments are not acceptable. There is evidence that it is more effective than placebo, but because there are more effective alternatives it is not recommended first line. However, experts agree that it is the safest option in the first 3 months of pregnancy [Scadding et al, 2008; Angier et al, 2010; BNF 64, 2012].

Nasal douching with normal saline moistens the nasal cavity and may promote mucociliary clearance. Saline solution also contains magnesium which may reduce inflammation of the nasal mucosa [University of Michigan Health System, 2007].

Oral corticosteroids for severe symptoms:

This is a pragmatic recommendation supported by the consensus opinion of experts and the British National Formulary [Wallace and Dykeqicz, 2008; ARIA, 2010; BNF 64, 2012].

The duration of treatment is based on the British Society for Allergy & Clinical Immunology (BSACI) guideline for the management of allergic and non-allergic rhinitis [Scadding et al, 2008].

The recommended doses for children and adults are based on expert opinion of CKS reviewers.

Use of intranasal decongestants:

Experts consider that in the short term, intranasal decongestants are effective in the treatment of nasal obstruction [University of Michigan Health System, 2007; Scadding et al, 2008; ARIA, 2010]. However, they are not recommended for regular daily use because of the risk of developing rebound congestion [Wallace and Dykeqicz, 2008].

Basis for not recommending sedating antihistamines and depot (slow release) corticosteroid injection [Scadding et al, 2008; Wallace and Dykeqicz, 2008]:

Although occasionally advantageous (for example to help sleep when taken at bedtime), sedating antihistamines can affect a person's ability to drive or perform other skilled tasks, as well as impair academic and work ability, and they have no benefits over the newer non-sedating antihistamines available [BNF 64, 2012].

Depot corticosteroid injections are not recommended by experts because the risk–benefit profile for intramuscular corticosteroids is poor compared with other treatments available.

Advice on avoiding allergens

When and how should I give advice about avoiding allergens?

Advise allergen avoidance for people with:

Suspected pollen allergy.

House dust mite allergy — when symptoms are inadequately controlled with maximal preventive drug treatment and the responsible allergen has been confirmed by allergy testing.

Suspected animal allergy — after confirming the responsible allergen by allergen testing.

Occupational allergy.

For people with grass pollen allergy, advise:

Against walking in grassy open spaces, particularly during the early morning, evening, and night, when pollen counts are at their highest.

Keeping windows shut in cars and buildings.

Changing car pollen filters with each service, if these are fitted.

For people with confirmed house dust mite allergy inadequately controlled by drug treatment, advise:

Fitting mattresses and pillows with house dust mite impermeable covers.

Using synthetic pillows and acrylic duvets, and keeping furry toys off the bed.

Washing all bedding and furry toys at least once a week at high temperatures.

If possible, choosing wooden or hard floor surfaces instead of carpets.

Fitting blinds that can be wiped clean instead of curtains. Surfaces should be wiped regularly with a clean, damp cloth.

For people with confirmed animal allergy, advise:

That ideally the animal should not be allowed in the house. When this is not acceptable, advise restricting their presence to the kitchen.

For people with occupational allergy, advise:

Eliminating or reducing exposure to allergens. For example using latex free gloves, using a dust mask, and ensuring that their environment is adequately ventilated.

Basis for recommendation

Basis for recommendation

These recommendations are based mainly on the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines [ARIA, 2010] and on expert opinion included in guidelines for the management of allergic rhinitis (provided by the British Society for Allergy and Clinical Immunology) [Scadding et al, 2008].

Recommendation on who to advise to try allergen avoidance:

House dust mite avoidance measures are not routinely recommended because they are inconvenient, expensive, and there is a lack of good quality evidence for their effectiveness. Skin prick testing, to confirm the responsible allergen, is indicated when such burdensome allergen avoidance strategies are being considered [Saleh and Durham, 2007].

Allergen avoidance is the most important measure for the management of occupational rhinitis and prevention of progression to occupational asthma; however, complete avoidance of allergens may not always be possible [Moscato and Siracusa, 2009; ARIA, 2010]:

If complete avoidance is not possible, reduction of exposure is an alternative approach, especially in people with occupational rhinitis at a lower risk of developing asthma.

However, in a person with latex allergy, reduction of exposure may not be enough to prevent the consequences of occupational allergy.

Recommendations on how to avoid allergens:

A Cochrane review (search date: December 2009) of allergen avoidance techniques for the control of perennial allergic rhinitis found nine relevant randomized controlled trials involving 501 participants [Sheikh et al, 2010].

Two studies investigated the efficacy of acaricide (a pesticide); two studies investigated the role of high-efficiency particulate air filters; one trial investigated the efficacy of both acaricide and house dust mite impermeable bedding covers in isolation and combination; and the remaining four studies investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers.

Two of the studies were of good quality, the remaining seven trials were small and of poor quality.

Results:

Of the nine studies included, seven reported a significant reductions in house dust mite load in the intervention group compared with the control.

The results suggest that the use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing the symptoms of allergic rhinitis and, if considered appropriate, these should be the interventions of choice. Isolated use of house dust mite impermeable bedding is unlikely to be effective.

No serious adverse effects were reported from any of the interventions.

Follow-up advice for well-controlled allergic rhinitis

What follow-up advice can I give to someone on treatment with well-controlled symptoms of allergic rhinitis?

Advise people who have adequate control of symptoms with drug treatment to continue treatment until they are no longer likely to be exposed to the suspected allergen:

For people allergic to house dust mite and people allergic to pets that remain in the home, symptoms are usually present throughout the year, requiring ongoing treatment.

For people allergic to tree pollens, treatment is usually required from early to late spring.

For people allergic to grass pollens, treatment is usually required from late spring to early summer.

For people allergic to weed pollens, treatment is usually required from early spring to late autumn.

Advise people who have recurrent episodes of allergic rhinitis controlled by intranasal corticosteroids, to restart treatment at least 7 days before re-exposure to allergens.

If the time of re–exposure is uncertain, such as the start of the pollination season, advise them to start treatment several weeks before the most likely time of re–exposure.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion from an Allergic Rhinitis and its Impact on Asthma (ARIA) guideline and are pragmatic [ARIA, 2008].

Scenario: Stepping-up treatment

Scenario: Stepping-up treatment for allergic rhinitis

24months3060monthsBoth

Treatment if symptoms are uncontrolled with initial treatment

What treatment can I offer if symptoms are uncontrolled with current treatment?

Reinforce advice about allergen avoidance, if applicable, and check compliance with first-line treatment.

For people taking an oral antihistamine, add an intranasal corticosteroid (such as budesonide, fluticasone, or mometasone) and review after 2 to 4 weeks.

For people using an intranasal corticosteroid, ensure they have a good technique. If they have, step up to the maximum licensed dose of the intranasal corticosteroid and review after 2 to 4 weeks.

For people with residual symptoms on a maximum licensed dose of intranasal corticosteroid, continue with treatment and:

If there is persistent nasal itch, sneezing, rhinorrhoea, or allergic conjunctivitis, add an oral antihistamine.

If rhinorrhoea persists despite combined use of intranasal corticosteroid and antihistamine, add an intranasal antimuscarinic drug (ipratropium bromide).

If nasal blockage is a problem, prescribe an intranasal decongestant for up to 7 days.

For people requiring rapid resolution of severe symptoms that are impairing their quality of life, start or continue treatments to control symptoms long term, and consider prescribing a 5–10 day course of prednisolone, 20–40 mg a day in adults and 10 mg a day in children.

For people with persistent symptoms despite being on maximal medical therapy, refer for specialist assessment and management.

Nasal spray and drop technique

Nasal spray and drop technique

Nasal spray technique [Scadding et al, 2008]:

Gently blow the nose to try and clear it.

Shake the bottle well.

Close off one nostril and put the nozzle in the other, directing it away from the midline. Tilt head forward slightly and keep the bottle upright.

Squeeze a fine mist into the nose while breathing in slowly. Do not sniff hard.

Breathe out through the mouth.

Take a second spray in the same nostril then repeat this procedure for the other nostril.

Nasal drop technique [ABPI Medicines Compendium, 2012a]:

Gently blow the nose to try and clear it.

Shake the container well.

Tilt the head backwards.

Place the drops in the nostril (squeeze the container gently if necessary).

Keep the head tilted and sniff gently to let the drops penetrate.

Repeat for the other nostril, if required.

See Prescribing information for more information on the recommended drugs.

Basis for recommendation

Basis for recommendation

Allergen avoidance:

The recommendation to reinforce allergen avoidance is based on an Allergic Rhinitis and its Impact on Asthma (ARIA) guideline [ARIA, 2010] and on expert opinion included in guidelines for the management of allergic rhinitis (provided by the British Society for Allergy and Clinical Immunology) [Scadding et al, 2008]. Experts agree that allergen avoidance is fundamental to the management of allergic rhinitis.

Combining intranasal corticosteroids and oral antihistamines:

Experts advise that a combination of an intranasal corticosteroid with an oral antihistamine can be considered for people who are unresponsive to, or noncompliant with, intranasal corticosteroids alone, although limited studies support this combination. The addition of oral antihistamines to intranasal corticosteroids generally did not demonstrate greater clinical benefit than intranasal corticosteroid monotherapy in controlled trials [Wallace and Dykeqicz, 2008].

Combination treatment with an oral antihistamine and an intranasal corticosteroid is also justified by the symptoms they control. In two systematic reviews [Weiner et al, 1998; Yanez and Rodrigo, 2002], intranasal corticosteroids were significantly more effective than oral and intranasal antihistamines at relieving symptoms of sneezing, nasal congestion, discharge, and itching, but were not significantly different for the relief of eye symptoms. However, there is evidence that oral antihistamines are useful for relieving the symptoms of allergic conjunctivitis associated with allergic rhinitis [University of Michigan Health System, 2007].

CKS identified a multi-centre observational study (n=1008) on the concurrent use of oral antihistamines and intranasal corticosteroids in people with allergic rhinitis. Results (from questionnaires) showed that GPs preferred, and more often used, combination treatment with oral antihistamines and intranasal corticosteroids, regardless of the frequency and intensity of allergic rhinitis [Navarro et al, 2011].

CKS recommends that the person is reviewed after 2–4 weeks. This is because the effects of intranasal corticosteroids are not immediate and may take a few weeks to be seen [University of Michigan Health System, 2007; Angier et al, 2010; ARIA, 2010].

Oral corticosteroids for severe symptoms:

This is a pragmatic recommendation supported by the consensus opinion of experts [Scadding et al, 2008; Wallace and Dykeqicz, 2008; ARIA, 2010].

Oral corticosteroids should not be considered as a first-line treatment for allergic rhinitis. However, they can be used for a few days as a last resort of treatment when combinations of other treatments are ineffective [ARIA, 2010].

Very disabling symptoms may warrant the use of oral corticosteroids for short periods, for example in students taking examinations. They may also be used at the beginning of a course of treatment with a corticosteroid spray to relieve severe nasal mucosal oedema and allow the spray to penetrate the nasal cavity, and to shrink large nasal polyps [BNF 64, 2012].

Intranasal ipratropium bromide:

Randomized controlled trials have shown that ipratropium bromide is effective in controlling watery nasal discharge [ARIA, 2010].

A study comparing the effectiveness and safety of intranasal corticosteroids with anticholinergics found that intranasal corticosteroids are more effective than anticholinergics for all nasal symptoms except rhinorrhoea [Wallace and Dykeqicz, 2008].

Intranasal decongestant:

Many experts consider that in the short term, intranasal decongestants are effective in the treatment of nasal obstruction [Scadding et al, 2008; ARIA, 2010]. Intranasal decongestants are not recommended for regular daily use because of the risk of developing rebound congestion [Wallace and Dykeqicz, 2008].

Basis for not recommending leukotriene receptor antagonists:

CKS expert reviewers do not recommend routine use of leukotriene receptor antagonists (montelukast and zafirlukast) as first–line treatment for allergic rhinitis in primary care. Some experts suggest that it may be considered as an add-on treatment for people with allergic rhinitis and asthma when symptoms are poorly controlled; however, there is a lack of evidence for their effectiveness as an add-on treatment, and their clinical role remains uncertain.

The British National Formulary advises that leukotriene receptor antagonists may be of benefit in people with exercise-induced asthma and in those with concomitant rhinitis [BNF 64, 2012].

Advice on avoiding allergens

When and how should I give advice about avoiding allergens?

Advise all people requiring step-up treatment about allergen avoidance.

For people with grass pollen allergy, advise:

Avoiding walking in grassy open spaces, particularly during the early morning, evening, and night, when pollen counts are at their highest.

Keeping windows shut in cars and buildings.

Changing car pollen filters with each service, if these are fitted.

For people with confirmed house dust mite allergy inadequately controlled by drug treatment, advise:

Fitting mattresses and pillows with house dust mite impermeable covers.

Using synthetic pillows and acrylic duvets, and keeping furry toys off the bed.

Washing all bedding and furry toys at least once a week at high temperatures.

If possible, choosing wooden or hard floor surfaces instead of carpets.

Fitting blinds that can be wiped clean instead of curtains. Surfaces should be wiped regularly with a clean, damp cloth.

For people with confirmed animal allergy, advise:

That ideally the animal should not be allowed in the house. When this is not acceptable, advise restricting their presence to the kitchen.

For people with occupational allergy, advise:

Eliminating or reducing exposure to allergens. For example using latex free gloves, using a dust mask, and ensuring that their environment is adequately ventilated.

Basis for recommendation

Basis for recommendation

These recommendations are based mainly on an Allergic Rhinitis and its Impact on Asthma (ARIA) guideline [ARIA, 2010] and on expert opinion included in guidelines for the management of allergic rhinitis (provided by the British Society for Allergy and Clinical Immunology) [Scadding et al, 2008].

There is a lack of good-quality trials examining the effect of house dust mite avoidance techniques in controlling the symptoms of allergic rhinitis.

A Cochrane review (search date: December 2009) of allergen avoidance techniques for the control of perennial allergic rhinitis found nine relevant randomized controlled trials involving 501 participants [Sheikh et al, 2010].

Two studies investigated the efficacy of acaricide (a pesticide); two studies investigated the role of high-efficiency particulate air filters; one trial investigated the efficacy of both acaricide and house dust mite impermeable bedding covers in isolation and combination; and the remaining four studies investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers.

Two of the studies were of good quality, the remaining seven trials were small and of poor quality.

Results:

Of the nine studies included, seven reported a significant reductions in house dust mite load in the intervention group compared with the control.

The results suggest that the use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing the symptoms of allergic rhinitis and, if considered appropriate, these should be the interventions of choice. Isolated use of house dust mite impermeable bedding is unlikely to be effective.

No serious adverse effects were reported from any of the interventions.

Follow-up advice for well controlled allergic rhinitis

What follow-up advice can I give to someone on treatment with well controlled symptoms of allergic rhinitis?

Advise people who have adequate control of symptoms with drug treatment to continue treatment until they are no longer likely to be exposed to the suspected allergen:

For people allergic to house dust mite and people allergic to pets that remain in the home, symptoms are usually present throughout the year, requiring ongoing treatment.

For people allergic to tree pollens, treatment is usually required from early to late spring.

For people allergic to grass pollens, treatment is usually required from late spring to early summer.

For people allergic to weed pollens, treatment is usually required from early spring to late autumn.

Advise people who have recurrent episodes of allergic rhinitis controlled by intranasal corticosteroids, to restart treatment at least 7 days before re-exposure to allergens.

If the time of re–exposure is uncertain, such as the start of the pollination season, advise them to start treatment several weeks before the most likely time of re–exposure.

Basis for recommendation

Basis for recommendation

These recommendations are based on expert opinion from an Allergic Rhinitis and its Impact on Asthma (ARIA) guideline and are pragmatic [ARIA, 2008].

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).

Antihistamines

Choice of antihistamine

Which antihistamines should I use to treat allergic rhinitis?

Oral non-sedating antihistamines:

Once-daily cetirizine, fexofenadine, and loratadine are recommended for the treatment of allergic rhinitis.

In pregnant and breastfeeding women, loratadine is recommended first-line. For more information, see Management of allergic rhinitis.

In children, cetirizine and loratadine are recommended.

Loratadine and cetirizine are licensed for use in children from 2 years of age.

Intranasal antihistamines:

Azelastine (applied two to four times daily) is the only intranasal antihistamine that is available and licensed in the UK for the treatment of allergic rhinitis.

Azelastine is licensed for use in adults and children aged 5 years and over.

Basis for recommendation

CKS does not routinely recommend the older sedating antihistamines for allergic rhinitis because:

Although older sedating antihistamines are effective, they are much more likely than the newer non-sedating antihistamines to cause drowsiness (which can affect a person's ability to drive or perform other skilled tasks), and several other options are available [BNF 64, 2012].

First generation antihistamines are associated with sedation, psychomotor retardation, and reduced academic performance [Greiner et al, 2012].

CKS does not recommend desloratadine (a metabolite of loratadine) and levocetirizine (an isomer of cetirizine) because although they are also licensed for the treatment of allergic rhinitis, there is little evidence to confirm whether they confer any additional benefit over the more established non-sedating antihistamines [MeReC, 2004; Bachert, 2009]; desloratadine and levocetirizine are only available as branded tablets making them more expensive than the other non-sedating antihistamines.

Evidence from a meta-analysis showed levocetirizine to be significantly more effective than loratadine in the treatment of allergic rhinitis (p < 0.01). However, the included studies compared loratadine or levocetirizine with placebo and not to each other (non-comparative studies). The authors advised that good quality direct comparative studies are needed to accurately compare the efficacy of one drug with the other [Mosges et al, 2011].

Treatments not recommended:

Mizolastine has been implicated in causing an abnormal prolongation of the QT interval and is therefore not recommended as a first-line treatment option.

Acrivastine is not recommended because it needs to be taken three times daily and is therefore less desirable from the perspective of adherence to therapy.

Rupatadine is not recommended because it is still under intensive post-marketing surveillance by the Medicines and Healthcare products Regulatory Agency (black triangle drug).

Adverse effects

What are the adverse effects of antihistamines?

Oral non-sedating antihistamines:

Non-sedating antihistamines are associated with a low incidence of drowsiness and sedation. However, these adverse effects may still occur:

Fexofenadine and loratadine do not cause sedation at recommended doses; however, loratadine may cause sedation at doses exceeding the recommended dose.

Cetirizine may cause sedation at recommended doses.

Advise people taking non-sedating antihistamines that some people may experience sedation, which may affect ability to drive, and that the sedative effects are enhanced when combined with alcohol.

Intranasal antihistamines:

People may experience a bitter taste after administration. This is often due to incorrect technique.

Basis for recommendation

Oral non-sedating antihistamines:

Although unlikely, drowsiness and sedation may still occur with non-sedating antihistamines, especially at high doses, because these drugs can penetrate the blood–brain barrier (although to a much lesser extent than sedating antihistamines) [DTB, 2002].

There are important differences among the second-generation antihistamines with regards to their sedative properties. Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses; however, loratadine and desloratadine may cause sedation at doses exceeding the recommended dose. Cetirizine and intranasal azelastine may cause sedation at recommended doses [Wallace and Dykeqicz, 2008].

An evaluation of the sedative properties of antihistamines found that fexofenadine causes the least sedation of the non-sedating antihistamines [Shamsi and Hindmarch, 2000].

Intranasal antihistamines:

The information on intranasal antihistamines is based on the British National Formulary [BNF 64, 2012].

Intranasal corticosteroids

Drug choice

Which intranasal corticosteroids should I use to treat allergic rhinitis?

Intranasal corticosteroids have similar clinical efficacy and selection preference varies among experts.

For people wanting a once daily preparation, prescribe budesonide, fluticasone, mometasone, or triamcinolone. Otherwise, prescribe beclometasone, betamethasone, and flunisolide which require more frequent administration.

Fluticasone is available as fluticasone propionate, 50 micrograms per metered spray and fluticasone furoate, 27.5 micrograms per metered spray, both of which are licensed for the prophylaxis and treatment of allergic rhinitis.

Fluticasone propionate is also licensed for the treatment of perennial rhinitis and nasal polyps.

For people with nasal polyps or marked nasal blockage making administration of topical treatments difficult, prescribe a short course of beclometasone or fluticasone drops until the nasal blockage improves.

Nasal sprays are preferred by experts for long-term use because:

They are more convenient to use.

There is more evidence for their effectiveness.

They generally have less systemic bioavailability and less potential for adverse effects.

For children, prescribe budesonide, fluticasone, and mometasone.

For pregnant women, prescribe budesonide, fluticasone, or beclometasone.

Basis for recommendation

Expert opinion from published articles is that intranasal corticosteroid preparations have similar clinical efficacy [Scadding et al, 2008; Wallace and Dykeqicz, 2008].

When comparing the available intranasal corticosteroids, the overall effect does not appear to vary significantly between products regardless of the differences in topical potency, lipid solubility, and binding affinity [Wallace and Dykeqicz, 2008].

The recommendation for managing nasal polyps and marked nasal blockage are based on the British Society for Allergy and Clinical Immunology Standards of Care Committee guideline for the management of allergic and non-allergic rhinitis [Scadding et al, 2008], and the British National Formulary [BNF 64, 2012].

The recommendation for managing pregnant women is based on the British National Formulary [BNF 64, 2012], the textbook Drugs During Pregnancy and Lactation [Schaefer et al, 2007], and a primary care allergic and non-allergic rhinitis guideline based on the British Society for Allergy and Clinical Immunology Standards of Care Committee guideline [Angier et al, 2010].

The BNF recommends that if a pregnant woman cannot tolerate the symptoms of allergic rhinitis, treatment with nasal beclometasone, budesonide, or fluticasone may be considered [BNF 64, 2012]

The recommendation for managing children is based on expert opinion from review articles.

Experts recommend budesonide, fluticasone, and mometasone because available trial data has shown that they appear to cause no adverse effects on growth in children [Schenkel et al, 2000; Yawn, 2006].

Adverse effects

What are the adverse effects of intranasal corticosteroids?

Systemic adverse effects caused by intranasal corticosteroids are rare, but systemic absorption may follow nasal administration especially if high doses are used or if treatment is prolonged (see the CKS topic on Corticosteroids - oral for adverse effects of systemic corticosteroids):

Monitor the height of children receiving high doses of intranasal corticosteroids over extended periods (more than 3 months) and review treatment if any effect on growth is observed.

Avoid corticosteroid nasal preparations in people with untreated nasal infections, and also after nasal surgery (until healing has occurred). This is to reduce the risk of systemic absorption.

The risk of systemic effects may be greater with nasal drops than with nasal sprays as drops are more likely to be administered incorrectly. Betamethasone drops have a higher systemic bioavailability and therefore a greater potential for adverse effects than other intranasal corticosteroids; fluticasone nasal drops are considered to have an extremely low systemic bioavailability.

Approximately 10% of users experience local adverse effects, including dryness, irritation, and nosebleeds (which may require stopping treatment for some time); reddening of the skin, rashes, and itching may also occur. Nasal ulceration has been reported, but occurs mostly with nasal preparations containing fluticasone furoate or mometasone furoate.

Concomitant use of other corticosteroids: when prescribing intranasal corticosteroids, take into account the use of other systemic and topical corticosteroids (for example creams, ointments, and inhalers). The effect of these drugs is probably additive and therefore requires close monitoring.

Basis for recommendation

Intranasal corticosteroids differ from oral corticosteroids in that they have relatively short half-lives, topical activity, and rapid first-pass metabolism [Yawn, 2006]. However, the Commission on Human Medicine (formerly Committee on Safety of Medicines) recommends that the height of children receiving high doses over extended periods be frequently monitored, and treatment reviewed if any effect on growth is observed [CSM, 1998; BNF 64, 2012].

Two placebo-controlled studies of budesonide aqueous nasal spray and fluticasone nasal spray have shown no significant effects on the speed of growth in children after 1 year of treatment, but similar placebo-controlled trials for other corticosteroids and comparative studies are lacking [Yawn, 2006].

The information on adverse effects and reducing the risk of adverse effects is based on the British Society for Allergy and Clinical Immunology Standards of Care Committee guideline for the management of allergic and non-allergic rhinitis [Scadding et al, 2008], and the British National Formulary [BNF 64, 2012].

The information on fluticasone is based on the Manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2012b].

Short course of oral corticosteroid

What do I need to know when prescribing a short course of an oral corticosteroid?

An oral corticosteroid should normally be taken as a single dose in the morning to reduce the disturbance to circadian cortisol secretion. It should also be taken with food to reduce the risk of gastrointestinal adverse effects.

Adverse effects are uncommon with occasional, short courses of oral corticosteroids.

If frequent courses of oral corticosteroids are needed, monitor people carefully for:

Growth retardation (children only).

Diabetes mellitus.

High blood pressure.

Osteoporosis.

For more information on the safe prescribing of oral corticosteroids, see the CKS topic on Corticosteroids - oral.

Basis for recommendation

These recommendations are based on the British National Formulary [BNF 64, 2012].

Intranasal decongestants

Choice of intranasal decongestant

Which intranasal decongestant should I prescribe?

Ephedrine and xylometazoline are recommended for up to 7 days to rapidly relieve nasal blockage.

For children aged 12 years and over, prescribe ephedrine 0.5% nasal drops and xylometazoline 0.1% nasal drops.

For children aged 6–12 years old, prescribe paediatric xylometazoline nasal drops (0.05%).

Do not prescribe decongestants to:

Children 5 years and younger.

Pregnant women.

Basis for recommendation

This information is based on the British National Formulary [BNF 64, 2012] and on a primary care allergic and non-allergic rhinitis guideline based on the British Society for Allergy and Clinical Immunology Standards of Care Committee guideline [Angier et al, 2010].

Adverse effects

What are the adverse effects of intranasal decongestants?

Long-term use of intranasal decongestants is associated with rebound nasal congestion upon withdrawal, which in turn encourages further use that can result in hypertrophy of the nasal mucosa (rhinitis medicamentosa). Therefore, a short course of up to 7 days is recommended.

Nasal burning, irritation, and dryness has been reported after their use.

Basis for recommendation

These recommendations are based on the British National Formulary [BNF 64, 2012], the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines [ARIA, 2010], and a published expert review article [Saleh and Durham, 2007].

Intranasal sodium cromoglicate

What do I need to know when prescribing intranasal sodium cromoglicate?

Intranasal sodium cromoglicate can be used in adults and children as an alternative treatment option to antihistamines and intranasal corticosteroids if they are not tolerated, but they are only partially effective.

Some people may experience local irritation on application; however, sodium cromoglicate is very well tolerated and is the safest drug recommended for allergic rhinitis in the first 3 months of pregnancy.

A disadvantage from a patient preference and compliance perspective is that it requires frequent dosing (up to 4 times a day) to be effective.

Basis for recommendation

This information is based on the British National Formulary [BNF 64, 2012] and the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines [ARIA, 2010], and on the British Society for Allergy and Clinical Immunology Standards of Care Committee guideline for the management of allergic and non-allergic rhinitis [Scadding et al, 2008].

Intranasal ipratropium

What do I need to know when prescribing intranasal ipratropium?

Intranasal ipratropium bromide is an option for add-on treatment in people with runny nose associated with allergic rhinitis.

Ipratropium bromide needs to be sprayed twice into each nostril, two or three times daily.

Localized adverse effects such as nosebleed, irritation, soreness and nasal dryness are common, but not usually severe.

Ipratropium bromide should be used with caution in people at risk of closed angle glaucoma as there have been case reports of ipratropium bromide precipitating this.

Basis for recommendation

This information is based on the British National Formulary [BNF 64, 2012], the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines [ARIA, 2010], and on the British Society for Allergy and Clinical Immunology Standards of Care Committee guideline for the management of allergic and non-allergic rhinitis [Scadding et al, 2008].

The recommendation for people with closed angle glaucoma is based on a textbook on drug interactions [Baxter, 2010].

Evidence

Evidence

Supporting evidence

Antihistamines

Evidence on the effectiveness of antihistamines

CKS could find no systematic reviews evaluating the effects of intranasal antihistamines However, there is evidence from placebo-controlled randomized controlled trials (RCTs) that antihistamines improve quality of life and rhinitis symptoms [Sheikh et al, 2007]. A similar benefit was found in most trials which compared intranasal with oral antihistamines.

A systematic review (search date: June 2002) investigated the effect of oral antihistamines on the symptom of nasal obstruction in people with persistent allergic rhinitis [Hore et al, 2005]. This review was conducted as oral antihistamines have been considered to have a limited effect on nasal obstruction [van Cauwenburge et al, 2000].

Of 89 potentially eligible studies identified, only seven met inclusion criteria and of these four (antihistamine group, n = 4, and placebo group, n = 126) contained data that could be pooled.

Meta-analysis found a weighted mean difference of:

–0.52 in favour of treatment for patient-assessed symptom scores (95% CI –0.73 to –0.31, p < 0.001). This represented a 32% change in symptoms on top of any placebo effect.

–0.33 in favour of treatment for healthcare worker assessed scores (95% CI –0.49 to –0.16, p = 0.0001). This represented a 22% change in symptoms on top of any placebo effect.

The authors therefore concluded that oral antihistamine use can result in a statistically significant improvement in nasal obstruction in people with persistent allergic rhinitis.

Intranasal corticosteroids

Evidence on the effectiveness of intranasal corticosteroids

Systematic reviews have found that intranasal corticosteroids have greater efficacy than placebo and antihistamines in treating all the symptoms of allergic rhinitis, except for allergic conjunctivitis where there appears to be little difference in effect between intranasal corticosteroids and antihistamines.

A systematic review (search date 1997) compared intranasal corticosteroids with oral antihistamines for allergic rhinitis [Weiner et al, 1998]. A meta-analysis of 16 trials (n = 2267) found that:

Intranasal corticosteroids were significantly more effective than oral antihistamines in relieving nasal blockage, nasal discharge, sneezing, nasal itch, postnasal drip, total nasal symptoms, and global ratings.

Treatments did not significantly differ in terms of nasal discomfort, nasal resistance, or eye symptoms.

A systematic review (search date 2001) compared intranasal corticosteroids with intranasal antihistamines for allergic rhinitis [Yanez and Rodrigo, 2002]. A meta-analysis of nine trials (n = 648) found that:

Intranasal corticosteroids produced significantly greater resolution of total nasal symptoms, sneezing, rhinorrhoea, and nasal blockage.

Treatments did not significantly differ in terms of ocular symptoms.

Significant heterogeneity was noted among the RCTs included.

A systematic review (search date 2003, five RCTs) compared once-daily intranasal budesonide with placebo in the treatment of allergic rhinitis [Stanaland, 2004]. The review was narrative and did not pool data, but found evidence from included RCTs that intranasal budesonide at varying doses was significantly more effective than placebo at decreasing nasal symptom scores.

A Cochrane review (search date September 2005) investigated the effectiveness of intranasal corticosteroids for intermittent and persistent allergic rhinitis in children [Al Sayyad et al, 2007]. Three trials (n = 79) were found which compared intranasal corticosteroids with placebo in perennial rhinitis.

All three trials provided some weak and unreliable evidence for the effectiveness of beclometasone and flunisolide used topically intranasally to treat intermittent and persistent rhinitis in children.

The authors concluded that use of these medications should be guided by the healthcare professional's clinical experience and the person's preference.

A meta-analysis (n=16 studies, 2,267 participants) of people with allergic rhinitis found that intranasal corticosteroids provided significantly greater relief of nasal congestion than oral antihistamines (95% CI for combined standardized mean difference, -0.73 to -0.53) [Nathan, 2008].

Intranasal sodium cromoglicate

Evidence on the effectiveness of intranasal sodium cromoglicate

Evidence from a systematic review and a Health Technology Appraisal suggests that intranasal sodium cromoglicate is more effective than placebo in the treatment and prevention of allergic rhinitis. It is not as effective as intranasal corticosteroids, and most trials also found sodium cromoglicate was not as effective as antihistamines. The four times daily administration of sodium cromoglicate is likely to reduce patient adherence and efficacy.

Guidelines on Allergic Rhinitis and its Impact on Asthma (ARIA) reviewed the evidence on intranasal chromones in people with allergic rhinitis [ARIA, 2010].

Intranasal sodium cromoglicate compared with placebo

The ARIA review identified one systematic review and one Health Technology Assessment (HTA) that assessed the relative efficacy of intranasal cromoglicate compared with placebo for the treatment of seasonal or perennial allergic rhinitis.

In the systematic review (25 studies):

The risk of treatment failure (as judged by the participants) was lower with intranasal cromoglicate compared with placebo (17 trials, n = 2299; relative risk [RR] 0.52, 95% CI 0.38 to 0.70).

Nasal symptoms were improved with intranasal cromoglicate compared with placebo (9 trials, n = 1036; standardized mean difference [SMD] -0.26, 95% CI -0.41 to -0.12).

In the HTA (32 studies):

In 30 of the 32 trials reported significant improvement in symptoms of rhinitis in people treated with intranasal cromoglicate compared with placebo.

In 16 of the studies, at least three of the five common symptoms associated with allergic rhinitis (nasal itch, sneezing, rhinorrhea, nasal congestion, or postnasal drip) were significantly improved by treatment with intranasal cromoglicate compared with placebo (congestion was the most unresponsive symptom).

No major adverse effects were reported.

The authors concluded that:

Intranasal cromoglicate is effective for reducing symptoms associated with allergic rhinitis; however, a good quality meta-analysis is needed to assess the magnitude of the effect and its precision.

Intranasal cromoglicate seemed to have higher efficacy in seasonal than in perennial allergic rhinitis.

Higher doses (including higher frequency of dosing) seemed to be more effective.

The need for administration four times daily is likely to reduce patient adherence and efficacy.

Intranasal sodium cromoglicate compared with intranasal antihistamines

The ARIA review identified one systematic review (4 trials, n = 332) that assessed the relative efficacy of intranasal antihistamines compared with intranasal cromoglicate.

The risk of treatment failure (as judged by the participants) was lower with intranasal antihistamines compared with intranasal cromoglicate (RR 0.46, 95% CI 0.31 to 0.68).

Studies showed that intranasal antihistamines were either more effective or similarly effective in relieving rhinitis symptoms compared with intranasal cromoglicate; no study favoured intranasal cromoglicate.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of allergic rhinitis.

Search dates

2007 - September 2012.

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

exp Rhinitis, Allergic, Seasonal/, exp Rhinitis, Allergic, Perennial/, (allergic adj rhinitis).tw., perennial.tw., occupational.tw., seasonal.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

Royal College of Physicians

Royal College of General Practitioners

Royal College of Nursing

NICE Evidence

Health Protection Agency

World Health Organization

National Guidelines Clearinghouse

Guidelines International Network

TRIP database

GAIN

NHS Scotland National Patient Pathways

New Zealand Guidelines Group

Agency for Healthcare Research and Quality

Institute for Clinical Systems Improvement

National Health and Medical Research Council (Australia)

Royal Australian College of General Practitioners

British Columbia Medical Association

Canadian Medical Association

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Singapore Ministry of Health

National Resource for Infection Control

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Patient experiences

Healthtalkonline

BMJ - Patient Journeys

Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

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ABPI Medicines Compendium (2012bp) Summary of product characteristics for Flixonase nasule drops. Electronic Medicines CompendiumDatapharm Communications Ltd. www.medicines.org.uk [Free Full-text]

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